Stanley K. Shapiro Application Package MIA AA I EACH BOARD AND COMMITTEE APPLICATION FORM
XA u p 1 re v t
Last Name First Name Middle Initial
. / S_i ,7 2, /gem CL 3
Home Address City State Zip Code
Home Telephone Work Telephone ellular Telephone Email address
Business Name Occupation
Business Address City State Zip Code
Professional License(describe): Expires:
Please attach a copy of currently effective professional license.
Pursuant to City Code section 2-22(4)a&b: Members of agencies, boards and committees shall be affiliated with the
City. This requirement shall be fulfilled in the following ways: a. An individual shall have been a resident of the City for
a minimum of six months; or b. An individual shall demonstrate ownership/interest for a minimum of six months in a
business established in the City for a minimum of six months.
• Resident of Miami Beach for a minimum of six(6) months: Yes W. or No LI
• Demonstrates ownership/interest in a business in Miami Beach for a minimum of six months:Yes Ilk or No LY.
• Are you a registered voter in Miami Beach: Yes or No
• I am now a resident of: North Beach South Beach . iddle Beach
• I am applying for an appointment because I have special abilities, knowledge and experience. Please list below:
• Are you presently a registered lobbyist with the City of Miami Beach?Yes Z1 or No
Please list your preferences in order of ranking [1] first choice [2] second choice, and [3] third choice. Please note that
only three(3) choices will be observed by the City Clerk's Office.
❑Ad Hoc Committee Centennial Celebration ❑LGBT Advisory Committee ❑Miami Beach Sister Cities Program
❑Affordable Housing Advisory Committee ❑Health Advisory Committee ❑Normandy Shores Local Government
Neighborhood Improvement
❑Art in Public Places Committee ❑Health Facilities Authority Board
0 Parks and Recreation Facilities Board °O
❑Board of Adjustment* ❑Hispanic Affairs Committee ❑Personnel Board
❑Budget Advisory Committee ❑Historic Preservation Board ❑Planning Board*`.`{
❑Committee on the Homeless %Housing Authority ❑Police Citizens Relations Committee
❑Committee for Quality Education in MB ❑Marine&Waterfront Protection Authority ❑Production Industry Council
❑Convention Center Advisory Board ❑Miami Beach Commission for Women ❑Sustainability Committee
❑Design Review Board'* ❑Miami Beach Cultural Arts Council XTransportation,Parking,&Bicycle-Pedestrian
Facilities Committee
❑Disability Access Committee ❑Miami Beach Human Rights Committee ❑Visitor and Convention Authority
* Board members are required to file Form 1 -"Statement of Financial Interest"with the State. -"'
*If you seek appointment to a professional seat (e.g., lawyer, architect, etc.) on the Board of Adjustment, ffesigrf Review
Board, Historic Preservation Board or Planning Board, attach a copy of your currently-effective license, Jd furnish the
following information: )
Type of Professional License License Number = `� `
License Issuance Date License Expiration Date -
OD
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°O Note: If applying for the Youth Center positions of the Parks and Recreations Facilities Board, please indicate your affiliation with
the Scott Rakow Youth Center and/or the North Shore Parks Youth Center:
• Please describe your past service with the City's Youth Centers(include dates of service):
• Present participation in Youth Center activities by your children:Yes No za
If yes, please list below the names of your children,their ages and the programs in which they participate:
Child's name: Age: Program:
Child's name: Age: Program:
• Have you ever been convicted of a felony?Yes or No La If yes, please explain in detail:
• Do you currently have a violation(s)of City of Miami Beach Code?Yes or N• If yes, please explain in detail:
• Do you currently owe the City of Miami Beach any money?Yes 11 or No IrA' If yes,explain in detail:
•Are you currently serving on any City Board or Committee?Yes Za or No FA If yes,which board/committee?
• In what organization(s)in the City of Miami Beach do yo currently hold membership? ��--
/f'I/ /11 g(h�, �, • - e • ` ,L ■■ Q/s o
Name Position
Name Position
• List all properties owned or in which you have an interest within the City of Miami Beach:
•Are you now employed by the City of Miami Beach?Yes or No
Which department and title?
• Pursuant to City Code Section 2-25 (b): Do you hsa parent , spouse Zt, child za brother or sister IZI1 who is
employed by the City of Miami Beach?Yes L9or No
If"Yes," identify person(s)and department(s):
The following information is voluntary and is neither part of your application nor has any bearing on your consideration for
appointment. It is being asked to comply with City diversity reporting requirements.
Gender: Male rAlli Female
Race/Ethnic Categories
What is your race?
African-American/Black
F41 Caucasian/White
Asian or Pacific Islander
Native-American/American Indian
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Other—Print Race:
Do you consider yourself to be Spanish, Hispanic or Latino/a?Mark the "No"box if not Spanish, Hispanic, Latino/a.
'A No
II I Yes
Do you consider yourself Physically Disabled?
No n:D Yes / I /1 '
NOTE: IF APPOINTED,YOU WILL BE REQUIRED TO FOLLOW CERTAIN LAWS THAT APPLY TO CITY BOARD/COMMITTEE
MEMBERS.THESE LAWS INCLUDE, BUT ARE NOT LIMITED TO:
o Prohibition from directly or indirectly lobbying City personnel(Miami Beach City Code section 2-459).
o Prohibition from contracting with the City(Miami-Dade County Code section 2-11.1).
o Prohibition from lobbying before the board/committee you have served on for period of one year after leaving office(Miami Beach
City Code section 2-26).
o Requirement to disclose certain financial interests and gifts(Miami-Dade County Code section 2-11.1).
o CMB Community Development Advisory Committee: prohibition, during tenure and for one year after leaving office, from having
any interest in or receiving any benefit from Community Development Block Grant funds for either yourself, or those with whom
you have business or immediate family ties(CFR 570.611).
o Sunshine Law - Florida's Government-in-the-Sunshine Law was enacted in 1967. Today, the Sunshine Law regarding open
government can be found in Chapter 286 of the Florida Statutes. These statutes establish a basic right of access to most
meetings of boards,commissions and other governing bodies of state and local governmental agencies or authorities.
o Voting conflict—Form 8B is for use by any person serving at the county, city or other local level of government on an appointed or
elected board, council, commission, authority or committee. It applies equally to members of advisory and non-advisory bodies
who are presented with a voting conflict of interest under Section 112.3143, Florida Statutes.
Upon request,copies of these laws may be obtained from the City Clerk.
I HEREBY ATTEST TO THE ACCURACY AND TRUTHFULNESS OF THE APPLICATION; AND I HAVE RECEIVED, READ AND
WILL ABIDE BY CHAPTER 2, ARTICLE VII, OF THE MIAMI BEACH CITY CODE, ENTITLED "STANDARDS OF CONDUCT FOR
CITY OFFICERS, EMPLOYEES AND AGENCY MEMBERS AND ALL OTHER APPLICABLE COUNTY AND/OR STATE LAWS AND
STATUTES ACCORDINGLY."
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Applic is Signature Date Name of Applicant(PLEASE PRINT)
Received in the City Clerk's Office by:
Name of Deputy Clerk Control No. Date
PLEASE ATTACH A CURRENT RESUME, PHOTOGRAPH AND A COPY OF ANY
APPLICABLE PROFESSIONAL LICENSE.
ATTACH ADDITIONAL SHEETS, IF NECESSARY, TO PROVIDE REQUIRED
INFORMATION.
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